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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1623505

Case Details

VAERS ID: 1623505 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Florida  
   Days after vaccination:166
Submitted: 0000-00-00
Entered: 2021-08-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: Altered state of consciousness, COVID-19, Cardiac arrest, Cardio-respiratory arrest, Cough, Death, Dyspnoea, Myalgia, Oxygen saturation decreased, Pulseless electrical activity, Resuscitation, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-18
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: acetaminophen, apixaban, vitamin C, aspirin, atorvastatin, bisacodyl, furosemide, levothyroxine, midodrine, niacin, nitroglycerin, fish oil
Current Illness:
Preexisting Conditions: HTN, CAD, Hyperlipidemia, Arrhythmia, Thyroid
Allergies: NKA
Diagnostic Lab Data: SARS CoV2 PCR COVID19 detected on 8/10/21
CDC Split Type:

Write-up: 8/10/21: He developed SOB, cough, and muscle aches, starting 3 days ago. He was referred to ER, where he was admitted on 8/10/21. Tested positive for COVID-19 on 8/10/21. 8/18/21: waxing and waning mentation, requires non-rebreather mask and desaturates quickly. In the afternoon of 8/18/21, he was found in cardiac arrest, PEA and code was called. Family requested to stop resuscitation given his age and poor prognosis. Time of death was called at 1628. Note: He received Pfizer vaccines on 2/3/21 and 2/25/21.

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